I watched The Other Boleyn Girl and haven’t been able to get it out of my mind. It wasn’t particularly fluid (without trying to be punny, I said, “It was choppy.”), but it prompted me to delve into the history of the family of Henry VIII.

What does this have to do with midwifery?

Two of Henry’s wives died in childbirth... and it got me thinking: It’s often said we need to go back to the basics, that birth is normal and natural, that we don’t need all the crap the hospital offers, that most care providers poke around and mess with the perfection of birth. Is this so?

The maternal mortality rate in the United States in 2005 was 15.1 women dying per 100,000 births... 1 in 6,700 women. In Sierra Leone, the country with the worst lifetime risk of maternal mortality, the rate is 1 death for every 8 pregnancies (not women, but pregnancies!). In developed countries, the lifetime risk is 1 in 2800 pregnancies. (I will address MMRs in more depth when I publish the third installment of this piece.)

For every woman who dies, THIRTY are left with permanent damage caused by birth – incontinence, infertility, hysterectomy, severe tears that do not heal properly, etc.

The earliest maternal mortality records come from the late 1500’s in England and because abortion was so forbidden, these would not include deaths by or after an abortion (as today's rates do include). The records show the MMR to be 2350 per 100,000, or 1 in 43 women died. In rural Germany, 1 in 20 women died in childbirth. In Europe, from 1666-1814, 2360 women per 100,000 live births died - 1 woman in 42. From 1700-1829, the rates lowered, starting as 1 in 36 women and changing to 1 in 100.

Did you skim over the statistics? Are you wishing I wasn’t talking about this? Is this too close to home?

Maternal death is so rare and hidden in our lives, it can be easy to push it behind us, leaving it in the shadows and reassure ourselves that “birth is as safe as life gets.”

Birth is saf-ER than it was; that’s a given. It’s saf-ER than in Sierra Leone, but that is just geography. In birth, there is risk and if we ignore it, we are not standing in the whole truth of informed consent – to birth (at all), to birth at home, to birth unassisted. I will examine why birth is safer today in subsequent posts – and, of course, midwives and doctors are going to be a part of the picture.

I encourage you to visualize the above statistics as REAL women... like you or me, like your sisters in on-line support groups, like your biological sister or aunt. These statistics are not just in our long ago past. These are in our here and now today.

One would presume that the women in Henry VIII’s family would have the best of the best care, yes? During that time, ruling families had an MMR of about 1 in 50. Not much different than in the general population.

Charles Brandon was Henry’s childhood friend who grew to be a lifelong confidante; his mother died in childbirth.

Henry VIII’s mother also died in childbirth.

Dipping into infant mortality, Catherine of Aragon, the first of Henry's wives, had six pregnancies and only one (the future Queen Mary I) lived past infancy. The others, all sons, died during their first few weeks of life.

Anne Boleyn, Henry's second wife, gave birth to a girl that lived past infancy (Princess Elizabeth) and then had a stillbirth and also a miscarriage, both boys.

Jane Seymour, his third wife, gave Henry his long-wished for heir, Edward. Jane died two weeks later of puerperal fever/sepsis (postpartum infection). During the pregnancy, Henry's first (illegitimate) son, Henry Fitzroy, died at 17-years old. Fitzroy had been Henry's only possibility for heir to the throne until a legitimate son was born.

Henry's fourth marriage to Anne of Cleves ended in an annulment; she seems to have never had children.

The fifth queen, Kathryn Howard, doesn't seem to have ever been pregnant (or there is no record of one) despite a long history of affairs - which led to her eventual execution.

Katherine Parr was Henry’s last wife... he died while married to her. After his death, she had one child, Mary, and died six days after her birth, also by puerperal fever. This was her only pregnancy of record.

Again, it fascinates me, all these infant and maternal deaths. 1 in 50 women died during that time. One woman dies every EIGHT pregnancies in our world today.

Huge initiatives exist to try and lower the infant and maternal mortality rates not only in our country, but around the world. These include educating midwives, bringing doctors to those that need them, utilizing pitocin to avoid postpartum hemorrhage, having antibiotics in case of infection and providing safe abortions and cesareans to the women who want or need them.

It’s so important to me that UCers, “freebirthers” understand what they are doing when they choose to birth with no care provider. If, after understanding the realities of death in birth, they decide to birth alone, at least they are making an informed decision. Burying one’s head in the sand about the risks is dangerous, not only to the woman and her baby, but to our entire society. We all pay for a member dying.

(Note: Because infant mortality rates are discussed so often, I am not addressing that topic here. But, those of us who work in birth will see at least one baby die during birth or right after. A baby dying isn’t as hidden, although we are certainly not de-sensitized to it. We shouldn’t be.)

Reader Comments (22)

The records show the MMR to be 2350 per 100,000, or 1 in 43 women died. In rural Germany, 1 in 20 women died in childbirth. In Europe, from 1666-1814, 2360 women per 100,000 live births died - 1 woman in 42. From 1700-1829, the rates lowered, starting as 1 in 36 women and changing to 1 in 100.

+++++++++

Just to point out, 2350 per 100,000 *births* is not the same as 1:43 women dying in childbirth, since, on average, women had more than than one birth each. Each birth had a 1:43 exposure, but a lifetime risk of childbirth-related death would have been much higher.

Not being a statistician, I did my best to read how the stats were broken out. *Some* of them specifically state blah blah per live births (the MMR, for example) whereas others spoke about a woman's lifetime risk. As far as I could tell, they looked like different statistics and were spoken about as such.

If I am wrong in how I wrote things, I am glad to correct them. But, from my non-statistician eye, this was how things looked to me. Any guidance otherwise is more than welcome!

This is the reason when people argue that every pregnancy should be taken to completion I attest that pregnancy is the most dangerous thing health-wise that a woman does as a choice and it should be done willingly only. Pregnancy is such a hard state to be in, and really even now has it's risks with modern medicine that I don't think that we should trivialize the enormity of the risks for a woman. A woman willing to have a baby is a gift, and should be left up to her to decide if she wishes to begin or if she wishes to end, it's not about what will be - there are no guarantees in pregnancy or childbirth.

I'm 3/4 of the way through Tina Cassidy's Birth: The Surprising History of How We Are Born and I skipped ahead to the conclusion at the end and she goes into some statistical analysis of MMR. Here's what she had to say:"In the nineteenth century, when most women around the world still gave birth at home, maternal mortality was fairly consistent at about 1%. While that number seems egregiously high today, tuberculosis killed more women of childbearing age than birth today."

To be honest, I was pretty impressed with that. 1/100 back in the 1800s-1900s, didn't seem too bad. I think I'd just been brainwashed by the "Birth is dangerous!" crowd and had the idea that it was much closer to the 1 in 8 that you're talking about. Also according to Cassidy's book, WHO breaks down maternal death into 25% hemorrhages, 15 % infection, 13% unsafe abortions, 12% eclampsia, and 8% obstructed labor (which includes placenta previa). I can absolutely see how basic hygiene, clean technique, clean water, and access to basic health care would dramatically change that 1:8 statistic.

I think that UC in the U.S. relatively nearby to a hospital, and using those basic precautions would have a better than 1/100 risk--although Cassidy also says that the risk for baby is about double that of the mother. That doesn't seem excessively risky to me. Comparatively, of course, you have a much much lower rate with a provider (either at home or in the hospital), but taking just the numbers, a less than 1% change of something happening is not terrible.

One percent seems "not that bad" when you consider how high the maternal mortality rate was in early hospitals, before doctors accepted the germ theory of disease. One percent certainly is better than 30 percent.

But it is 100 times worse than the rate we have today in the United States.

I'll accept that a lot of the primary causes - obstructed labor, infection, hemorrhage (depending on how bad) - are things that even a UCer could respond to if necessary by seeking out medical treatment/calling 911. But it doesn't mean the issues shouldn't be taken seriously.

Our bodies aren't "designed" to give birth. We have evolved a way to get our big-headed babies through our narrow pelvises that is sufficiently effective that more mothers and babies live than die. Like a lot of people who care about birth and birth choices, I get my hackles up when people go on and on about how dangerous birth is. But we shouldn't pretend that sometimes it just doesn't work the way it is supposed to.

I am not an expert but I would like to point out all the other factors that play into a healhty birth. Like the earlier commenter said, medical asepsis like hand washing, clean water etc. had an effect in addition to peoples overall health. Nutrition and disease played a role as well. No one was being vaccinated, pregnant women have suppressed immune systems... things like that. Life was also harder for people everyday.

Conclusion: We used to be thin, exhausted and diseased and now we are fat, fertilized and medicated... and moms and babies die no matter what.

One of the things MMRs do is remove disease from the deaths related to pregnancy. Even if the disease worsened because of the disease, they did not consider it part of the results.

It is absolutely correct that dirt and germs had a huge impact on births before the late 1800's when we realized/learned what caused infection. Reading, it was disgusting to learn doctors used to pride themselves on how much pus and blood they could get on their clothes and aprons. How many, many women had to have died from something so painful as sepsis when they didn't have to.

It makes me wonder what we don't know now that we might learn about tomorrow. Will there be a day when our granddaughters gasp at how little we knew?

The fact that you're looking to Henry VIII is fascinating... there's a lot of speculation that Henry might have had either syphilis (acquired some time after Mary's birth, as both Edward and Elizabeth show some signs that could possibly have been congenitial syphilis) or some sort of chromosomal problem that was linked to the Y chromosome. It seems to stretch credulity that Katherine would lose 6 male babies, Anne would lose two while both gave birth to reasonably healthy girls. Although, I wonder if Rh incompatibility could have been an issue?

Not that I don't think you've got a great point about safety in birth. I'm just fanatically Tudor-obsessed and felt the need to share.

You know what I love best about you and your writing is that you're not afraid to think , say and write the most unpopular thing in the alternative birth community. I'm surprised you have not received more vicious responses from the Mothering.com UC gals!

I'm 52 and part of the first wave of alternaive birth community, I do not believe this new wave of young women having UC are considering their baby could die or they could die. That being said I do not believe birth is unsafe on a personal basis for a helathy women at home. Institutionally it becomes less safe.

I do think many women who plan on having a UC are lieing to themselves, they are not really unassisted birth, but unassisted by a professional as long as all is going well. Babies can birth themselves. If you invite trained labor doulas, and friends to the birth. Then lie to doctors and midwives so the pregnancy can become legal, and "accidentally" on purpose don't call unless you are panicking about the way the labor is progressing is that unassisted birth.

I always wondered what a family does with a baby who died at home during an unassisted childbirth, or if the women dies. I wonder if these freebirthing are the same women screaming anti-choice rhetoric and belive firmly they should have reproductive rights to choose where and how they give birth. If so, Reproductive rights have to extend to all of a womens choice about birth.

How would they explain themselves that they choose to forgo all professional care prenatally and during birth. Should child protective services consider that parental negligence, murder, if the baby dies during birth?

I would consider UC if I lived in a place with hospitals that were heavily medical minded and an attended home birth wasn't an option. I read online about so many places where women lack options in North America. I suspect if women felt more supported in their choices, less of them would choose UC in the first place or even consider that option.

How many, many women had to have died from something so painful as sepsis when they didn't have to.

One bit that was quite disturbing to me in Tina Cassidy's book was reading about how doctors figured out that germs spread disease and hand-washing can stop or very much limit its spread THREE!!! times over a periord of nearly 100 years before it finally became accepted. Reading about all the theories that blamed women for post-partum infections as the mortality rate in laying-in hospitals soared to 40 percent and doctors refused to believe they might have any role in it even as the answer had already been given to them just made me sick to my stomach.

It makes me wonder what we don't know now that we might learn about tomorrow. Will there be a day when our granddaughters gasp at how little we knew?

Well....you know where I stand on this issue, I think. I am convinced that many, if not most, of the UC community is grossly uninformed, or misinformed, about the risks they are taking. I am very concerned when someone says that "such and such" a number "doesn't seem like a very big risk to me". The fact is, someone will be that "such and such" number and it could well be you and that, frankly, is the only important question to ask: if it is you, or your baby, are you prepared to accept that risk, and that outcome, and to assume the responsibility and accountability inherent in that choice? I have been offering open and free council to UC women and families for years now. I ask that question, exactly that way, every time, to every woman/couple. Only twice have they continued with plans to UC and this is dozens of families; not a few. As a midwife, I have become truly horrified at the level of denial involved in the decision to UC far too much of the time. The idea is that they have "informed and educated" themselves but too often, some reasonable probing shows a real disconnect between what they think they "know" and know how to do; and what the reality of something is ie. what something will actually look like, sound like, feel like, or how deadly fast something can become an overwhelming mess! Every midwife practicing for longer than a couple of years knows that moment when someone's blood is pooling at our feet and a baby is struggling to breathe when we wish we had chosen something...ANYTHING else to do for work! I vividly recall the first real emergency I had to handle; a severe shoulder dystocia in a grand multip followed by a torrential bleed. Over literally 10 minutes time, we went from laughing and starting to push out a nice sized, healthy baby, to being in the middle of an emergency that required medication, oxygen, ambu bag and transport. Everyone was alright in the end but I quickly got over any remnant of any notion that birth was benign, "safe" or problems easily and quickly resolved. Birth is a reliable, known quantity; so is a hurricane. We can know what birth is, and how it generally behaves but, like all things in nature; it can throw some very nasty curveballs. I think it's ironic and odd that people who are most likely to identify themselves as "green" and "committed to respecting nature" and the like actually seem to respect it very little, given that they seem to assume it will behave according to something other than it's own whims. Nothing in nature is predictable; caution, prudence and true respect are always in order. Never more than in birth.

One more thing I wanted to add: I believe deaths from illegal abortion are counted in all those maternal mortality rates. While they don't account for the majority of maternal deaths, in many countries it's in the double-digits as a percentage of maternal deaths. Making abortion illegal doesn't stop abortion from happening. It just ensures many more women - many of them already mothers of living children - will die.

I believe that a lot of the fact-denial in natural birth advocates (of whatever stripe, and I say that as one myself) is due to the defensive posture you automatically get pushed into in this society, and to a resistance to further trauma.

In other words, the extremism of the modern hospital has bred the extremism of those who birth with too little assistance or information. Extremism works like that. I think that many women would be perfectly willing to discuss birth risks realistically, except that there seems to be no middle ground for most of us; to admit to risks at all seems to be likely to put you back in the maternity ward, flat on your back, pumped full of pitocin, immobilized by epidurals, separated from your screaming baby, and disempowered and hurt again.

The natural birth (especially VBAC!) community is *full* of traumatized women, and many will seek out UC because there *is* no place that feels safe for them to birth with assistance. In cases of VBAC, hospitals and birth centers still actually turn them away if they refuse to be cut again, regardless of health.

Education is great, and definitely these topics must be discussed, but until we can make midwife/birth center births more available and hospital births less like assault, there will always be lots of traumatized women who want to UC risks rather than hospital risks.

As a c/sec traumatized mom myself, I can hear what you're saying, but I also feel how it can sound to those women, and it sounds like blaming. We can't scold them into being safe, we have to make safe practice safe for them mentally and emotionally as well. Or else it feels like just telling them to stop being stupid and whining about being hurt during birth. And that's not acceptable.

i am so glad that you are opinionated, so am i. which is why i must respectfully disagree with some of your conclusions in this piece. full disclosure: i am one of those folks who advocate for women to have the choice to free birth. i believe in reproductive choice for all people. and it is the fact that i believe in abortion rights and the right to herbal home abortions that brought me to an understanding that free birth is also a choice that needs to be respected. i have lived and worked in low-intensity conflict zones in the third world and can say that there are alot of conditions that lead to high mmr, it is not just geography. mothers deaths are often attributed to the lack of clean water, or good food. women have died because of military closures that dont allow for women to leave their house for weeks on end. as well as being subjected to physical violence during the war. and the mental, emotional and physical stress that comes from living in a war zone. in many countries rape is used as a weapon of war and the trauma weakens the mother's body and soul. furthermore women often work in physically strenuous jobs (carrying 50 lbs on their back up a mountain daily or in sweatshops crouched over for 10 hours day) for long hours in order to provide for the basics in their family. then you have to consider that many third world areas the women live in environments that have been stripped polluted and damaged, thus the very air that they breathe can compromise the body's strength. considering all this it is amazing that women are able to give birth at all. but they do. while i have met women who have been traumatized by their births (and i am one of them) i have also met midwives who have been traumatized by the births they have attended (esp in the cases of infant death or even having to transfer a client). and often the midwives way of dealing with the trauma is to become more controlling, less trusting, more likely to use fear as a way to convince mothers, less flexible, less open-minded and more interventionist 'for the good of the mother'. and it is sad to see midwives try to avoid being traumatized rather than focusing on the mother's empowerment.i believe that all women should be informed of all their reproductive choices and the risks and benefits of those choices. maybe it is because i have worked in war zones that i believe always in life there is the risk of death. that people can be given the same information, and yet make different choices and choose different forms of risks. that communities are stronger when we respect people's choices.

Rh disease makes a lot of sense with regard to the Tudors, especially given Mary I ("Bloody Mary") never had a live birth but suffered many, many losses, to the point of it causing her to crack up mentally. She may well have been the sole surviving birth from her mother because she, too, was Rh-.

I think that most women who choose to free birth don't really understand how quickly things can go wrong. They believe that there's time to call an ambulance. There's time for them to recognize the problem / complication. They believe that they will be able to communicate their needs to their partner.

Unfortunately, that's not always the case. As someone who's experienced a complicated labor and delivery, I can say that it took less than 3 minutes from the moment I first started thinking something wasn't quite right until I was completely incapable of voicing my needs. It was less than three minutes to go from a competant participant to being completely incapable of making decisions for myself. Three minutes to go from understanding to smothered in fear.

There's no way that in those three minutes I would have been able to diagnose some pretty rare obstetrical complications, explain to my husband to call 911, and convey what I thought might be the proper treatment options until help arrived all while trying to keep a newborn baby safe and warm.

I admit that my situation was far from normal. I know that "most" of the time things work out just fine. The problem is that you never know who is going to be the exception. I have to say that before my daughter's birth the odds of 1 in 100 wouldn't have bothered me much. However, after having a birth where the odds of the all of my complications happening in a single delivery are around 1 in 1,000,000,000 - 1 in 100 scares the bejesus out of me.